Twenty years back, it was just another busy morning and the very thought of a hectic admission day at the medicine department was giving enough heartburn. While rushing to the medical college OPD, there was this unusual sight of men in blue uniforms that caught my attention. In the pre-internet and social media proliferation era, even the pictures of Special Forces like the Rapid Action Force (RAF) were rare; seeing them in real life was special. On a closer look, they were busy cleaning the premises of our teaching hospital. The men in blue uniforms with their professionalism and discipline had done a thorough job in a short time. The premises had an immaculate and clean look the very next day. Undoubtedly, a new normal was set when it came to cleanliness, though with the passage of time, everyone seemed to forget it. And then, things crawled back to the good old grimy ways soon.
Fast forward to 2019, one still gets to hear horrifying stories on the lack of cleanliness in many of our government hospitals. One such instance was cited recently by a fellow twitterati after she spent about two weeks by her parents in the ICU of one of India’s oldest medical colleges counted as amongst the most premier institutions in the country. While she was all praise for the dedication and efficiency of doctors and nursing staff, the graphic description of the pathetic state of sanitation and hygiene at this teaching hospital was cringe worthy. This is not an isolated example, and many of you may have come across similar experiences of unclean health facilities, premises and poorly maintained infrastructure across the country.
The W-A-S-H Crisis
Let’s face it, almost 80% of govt. hospitals in India are overcrowded and are serving patients much beyond their capacity. Every worthy hospital would have standard operating procedures on different aspects like cleaning, decontamination and sterilization. The type and frequency of routine cleaning depends upon clinical risk, surface characteristics, patient turnover and intensity of people-traffic. While there are multiple facets to maintaining hospitals, let’s focus today on Water and Sanitation Hygiene (WASH).
Researchers have attributed lack of WASH to be one of the leading risk factors driving most deaths and disabilities in India. According to a recent survey across six Indian states by WaterAid India Advocacy, almost 343 healthcare institutions lacked basic hygiene, toilets, clean water and waste disposal. Other surveys conducted on behalf of the Ministry of Health and Family Welfare has also evaluated hand-hygiene. On a scale of 1 to 10, with 10 being the best quality, the average hand-hygiene score in district hospitals was 4.35, while the same for CHCs and PHCs respectively were 3.01 and 1.42. The bottom line is that WASH, which should be the primary concern, is lacking in government hospitals. While the hospital administration and staff have their own challenges to tackle, it’s true that the general public, patients, their families and friends too could contribute to the cause.
We want the government to book the big defaulters of bank loans before any other loan defaulters are asked to pay up. We want each pot-hole on every road be set right before hefty fines are imposed by the traffic police. When e-cigarettes are banned, many have an issue for not banning the normal cigarettes. Scientists vouch for the fact that behavioral change of any kind is tough because the human brain adores status quo, and this is true even if the existing behavior can cause huge negative consequences. Changing the behavior, more so in a large diverse country like India, is even more difficult.
Despite this inertia to change, we can now find an increasing number of success stories. The Swachh Bharat Mission (SBM) that has won global acclaim is probably the largest irreversible behavioral change programme in the world. The mission shifted its initial focus from production outputs (i.e. toilet construction) to behavioral outcomes (i.e. open-defecation-free). In some parts of the country, more so at the primary and secondary healthcare centers, we can experience cleanliness and hygiene that matches the best of the private institutions. Another recent campaign by Delhi govt., '10 Hafte, 10 Baje, 10 Minute' urges the public to inspect their households to prevent mosquito breeding grounds. Following the success in several countries like US, UK and Australia, India will soon have a behavioral ‘nudge’ unit that will develop behavioral strategies to compliment policy decisions. Shall we then assume that change is the constant in the new India?
Maintenance of the hygiene and cleanliness of health facilities is not only related to aesthetics and patient satisfaction, but also reduces the burden of Hospital Acquired Infections (HAI). Govt. of India had set up a high power committee with the objective of changing the perception and mindset of people about public hospitals through the highest level of hygiene and sanitation. One of the key outcomes was drafting the National Guidelines towards the same. While the administration is at it, such an exercise cannot be achieved without public support. Change need not always be dependent on the state, or big bang reforms, but a million small fixes. Let me call this ‘Destination Zero’ with some simple pointers below:
Zero Littering: From beaches to streets to hospitals, littering is endemic in India. The fact that healthcare facilities are meant ‘for the people’ must be appreciated and supported ‘by the people’. Sense of belonging that ‘it’s our place’ is one of the first steps to course correction. The concept of Swachchatha (cleanliness) is not of just cleaning up, but also of not dirtying up places.
Zero Visitors: Too many people visiting or accompanying patients add to a lot of avoidable foot-falls and thereby hygiene burden to every facility. Let’s try to minimize, if not avoid this. Mobile devices and virtual communication tools are part of our life, be it business or personal. Why not use same methodologies to interconnect, more so from a place prone to contamination and diseases? Even if families want to meet with the attendants of patients, let this be arranged in common areas designated in hospitals, rather than letting everyone walk through the wards and ICUs. Technology used in simple appointment bookings can enable each family to book slots at their convenient time rather than fixed visiting hours.
Zero Contamination: Even when that visit to the hospital is inevitable, it’s worth remembering these. Three-quarters of patients' rooms are contaminated with organisms that can cause infections. No part of our skin is spared from bacteria and the count may range from five thousand to five million colony forming units per square centimeter. And the most common way infections are contracted is person to person via hands or touch. Hand washing and usage of alcohol gels are common practice, and hospitals are striving to achieve 100% compliance from its staff. Every time, every visitor need to be diligent to sanitize their hands before and after patient visits.
Many more zeros could be added to this journey towards destination cleanliness. In our country, many may still jump queues, drive through one-ways and dump garbage on the streets. But a country aspiring to be a USD 5 trillion economy will need new rules, benchmarks, habits and behaviors across multiple spheres of life. We need revamped motor vehicle rules, bullet trains with bio-toilets, precision agriculture, Rafale jets, green energy and of course, cleaner hospitals. On the occasion of the 150th birth anniversary of the Father of our Nation, maybe it’s time that each of us pledge to take steps to keep our centers of hope and healing cleaner. Time for a Swachh Aspathaal Mission?
Post-script: Even today, after walking into many medical college hostels you’ll be excused for believing in time travel, and for being transported to the nineteenth century infrastructure. May be that’s our establishments’ way of acclimatizing budding doctors and nurses to our Govt. hospitals. More of that on another occasion!
The author is Co-founder & Director @ BioQuest Solutions, a globally emerging Knowledge Services Organization that has been partnering with clients across the life-sciences value chain since 2005.